Friday, June 24, 2011

Dr. Marsha Linehan and the Sources of Creativity

An article in yesterday's New York Times told how Dr. Marsha Linehan, developer of Dialectical Behavioral Therapy (DBT), a profoundly innovative and uniquely effective approach to chronically suicidal patients, "came out" about her own history of chronic suicidality.

As a teen-ager in Tulsa, Oklahoma, Dr. Linehan, who is now 68, experienced increasing depression and self-injuring behaviors, leading to hospitalization at the Institute for Living in 1961, at age 17. She spent two years at the hospital, often cutting herself, burning herself, and banging her head against the wall when she was put into seclusion, which happened often. She was treated with psychotherapy, medication and two courses of electroconvulsive therapy. Nothing helped.

On discharge Dr. Linehan was older, but not yet healthier. She was, however, determined. Here's what she says in retrospect: "I was in hell. And I made a vow: when I get out, I’m going to come back and get others out of here." Where that spark of resilience came from is a mystery. But wherever it comes from, it's something we need to cultivate in ourselves, and, as physicians, in patients who suffer from chronic conditions, whether of mind or body.

Dr. Linehan returned to Tulsa, then went to Chicago to try to find her way. She experienced more depression and suicidality, and was hospitalized again. She frequently went to church to pray. One night in her mid 20s she had a remarkable experience: "I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me. It was this shimmering experience, and I just ran back to my room and said, 'I love myself.' It was the first time I remember talking to myself in the first person. I felt transformed." She went back to college, studied psychology, got a PhD, and subsequently made history!

I've never met Dr. Linehan or trained in DBT, but I've referred many patients to DBT programs and saw it through their eyes. This post isn't the place to try to summarize the DBT method, but as I see it, the components of DBT were familiar and on hand - behavioral therapy, cognitive therapy, meditation, and psychoeducation. Dr. Linehan's unique contribution was to show how the pieces could be orchestrated together to achieve outcomes that none were able to accomplish alone.

My guess is that what enabled Dr. Linehan to do this - in addition to her brilliance and skill - was her empathic understanding for and deep commitment to the patient population she developed DBT to serve. She understood, from within, how pained and vulnerable these patients are, and, at the same time, how they need to be pushed. In other words, tough love. And perhaps from empathy for the many therapists who struggled, initially ineffectively, to help her, Dr. Linehan has focused as well on helping therapists develop the skills and supports they need to do the difficult clinical work.

In the "coming out" lecture she gave at the hospital she spent two years at as a teen-ager, Dr. Linehan said - "So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward." I found this very moving. She has already created an objective legacy by developing a clinical approach and subjecting it to rigorous evaluation, but she wanted to bring in the subjective component of her own life experience as well.

Outcome studies speak to evidence based medical practice. Her life story speaks more widely to hearts as well as minds.

In William Butler Yeats's late poem "The Circus Animal's Desertion" the poet starts by lamenting a period of emptiness, and then reviews the great poems he'd written. In the final stanza he asks where these creative achievements came from. Here's the question and his answer:

Those masterful images because completeGrew in pure mind, but out of what began?A mound of refuse or the sweepings of a street,Old kettles, old bottles, and a broken can,Old iron, old bones, old rags, that raving slutWho keeps the till. Now that my ladder’s gone,I must lie down where all the ladders startIn the foul rag and bone shop of the heart.

In her late teens and 20s Dr. Linehan was down and out, but she had the courage to "lie down where all the ladders start," with truly inspiring results!